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Royal Cornwall Hospital Requires improvement

All reports

Inspection report

Date of Inspection: 25 January and 25 May 2011
Date of Publication: 29 June 2011
Inspection Report published 29 June 2011 PDF

Staff should be properly trained and supervised, and have the chance to develop and improve their skills (outcome 14)

Meeting this standard

We checked that people who use this service

  • Are safe and their health and welfare needs are met by competent staff.

How this check was done

Our judgement

Poor morale, feeling undervalued and under pressure staff are more at risk of making mistakes putting the safety of patients undergoing surgery at risk. Although changes are being made, further improvements are needed to improve the safety for patients undergoing surgery.

User experience

Understanding of the occurrence of never events at the hospital varied between staff we spoke with. Two staff told us they had been told about the retained swabs during one of the team briefings with a reminder to double check swabs at the end of surgery. One anaesthetist said he had been informed at a clinical governance meeting and an operating department assistant said they had received an email. consultants had heard about previous ‘never events’ and one was not aware of any of the ‘never events’. No staff knew about the cluster of ‘never events’ therefore no one understood there was a theatre safety issue.

Not all staff felt valued. We were told that some nurses were being interviewed as part of a re-grading process and this had had some effect on staff morale, especially as some staff had had their interviews five weeks ago and still did not know the outcome. Other staff said that requests for equipment were not acted upon and others said there were concerns about skill mix.

Staff told us that they fell under pressure to complete the paperwork and the computer system whilst the operation is ongoing. One person was pleased that the operation being observed was a training operation as it would be slower and therefore there would be more time to complete the documentation.

We were told that the staff working in the theatres have access to relevant training, support each other and get ongoing support form theatre managers

Other evidence

There has been no formal training for all grades of staff within the operating theatre departments in relation to the implementation and use of the WHO checklist and how that can prevent ‘never events’ occurring.